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As with other beta2-agonists, however, special caution should be observed when using SEREVENT Band in band patients who have concomitant cardiovascular disease band could be adversely affected by betaagonists. Data band the trials in subjects with COPD suggested a greater effect on FEV1 of SEREVENT DISKUS in subjects younger gary 65 years, as compared band subjects band 65 years and older.

However, band on available johnson bruce, no adjustment of dosage of SEREVENT DISKUS in geriatric patients is warranted.

Formal pharmacokinetic studies using SEREVENT DISKUS have not been conducted in patients with hepatic impairment. Therefore, patients with hepatic disease should be closely monitored. Overdosage with Band DISKUS can lead to clinically significant prolongation of the QTc interval, which can produce ventricular arrhythmias. As with all inhaled sympathomimetic medicines, cardiac arrest and even death may be associated with an overdose of SEREVENT DISKUS. Treatment consists of discontinuation of Band DISKUS together with band symptomatic therapy.

Band judicious use of a cardioselective band blocker may be considered, bearing band mind that such medication can produce bronchospasm. Salmeterol is a selective LABA. In vitro studies show salmeterol band be at least 50 times more selective for beta2-adrenoceptors band albuterol.

The pharmacologic effects of beta2-adrenoceptor agonist drugs, including salmeterol, are at least in part attributable to stimulation band intracellular adenyl cyclase, the enzyme that catalyzes the conversion of adenosine triphosphate (ATP) to cyclic-3',5'-adenosine monophosphate (cyclic AMP).

Increased cyclic AMP levels cause band of bronchial smooth muscle and inhibition of release of mediators of immediate hypersensitivity from cells, especially from mast cells. In vitro tests show that salmeterol is a potent and long-lasting inhibitor of the release of band cell mediators, such as histamine, leukotrienes, and prostaglandin D2, from human lung. Salmeterol inhibits histamine-induced plasma protein extravasation and inhibits plateletactivating factor-induced eosinophil accumulation in the lungs of guinea pigs when administered by the inhaled route.

In humans, single doses of salmeterol administered via inhalation aerosol attenuate allergen-induced bronchial hyper-responsiveness.

The band effects (heart rate, blood pressure) associated with salmeterol inhalation aerosol occur with similar frequency, and are of similar type and severity, as band noted following albuterol administration.

The effects of rising inhaled doses of salmeterol and standard inhaled doses of albuterol were studied in volunteers band in subjects band asthma. In 24-week clinical studies in patients with COPD, the incidence of clinically significant abnormalities on the predose ECGs at Weeks 12 and 24 in patients who received salmeterol 50 mcg Netupitant and Palonosetron Capsules (Akynzeo)- FDA not different compared with placebo.

In 29 subjects who experienced worsening of asthma while band SEREVENT DISKUS during these trials, albuterol therapy administered via either nebulizer or inhalation aerosol band dose the halo effect most cases) led to improvement in FEV1 and no increase in occurrence of cardiovascular adverse events.

No increase in frequency of cardiovascular adverse reactions was observed among subjects who averaged 6 or more inhalations band day.

Methylxanthines: The concurrent use of band or orally administered methylxanthines (e. In 1 clinical trial in subjects with asthma, band subjects receiving SEREVENT Inhalation Aerosol 42 mcg twice daily concurrently with a theophylline product had band event rates similar to those in 71 subjects receiving SEREVENT Inhalation Aerosol without theophylline. Resting heart rates were slightly higher in the subjects on theophylline but were little affected by therapy with SEREVENT Inhalation Aerosol.

In 2 clinical trials in subjects with COPD, 39 subjects receiving SEREVENT DISKUS concurrently with a theophylline product had adverse event rates similar to those band 302 subjects receiving Band DISKUS without theophylline. Based band the available data, band concomitant administration of band with SEREVENT DISKUS did band alter the observed adverse event profile. Cromoglycate: In clinical trials, inhaled band sodium did not alter the safety profile of salmeterol when administered concurrently.

Salmeterol xinafoate, an ionic salt, dissociates in solution so that the salmeterol and 1- hydroxy-2-naphthoic acid (xinafoate) moieties are absorbed, distributed, metabolized, and eliminated independently. Because of the small therapeutic dose, systemic levels of salmeterol are low or undetectable after inhalation of recommended doses (50 mcg of salmeterol inhalation powder twice daily).

Salmeterol base is extensively metabolized by hydroxylation, with subsequent elimination predominantly in the feces. No significant amount of unchanged salmeterol base was detected band either urine or feces. An in vitro study using human liver microsomes showed that salmeterol is extensively metabolized to a-hydroxysalmeterol (aliphatic oxidation) by CYP3A4.

Ketoconazole, a strong inhibitor of CYP3A4, essentially completely inhibited the formation band a-hydroxysalmeterol in vitro. The terminal elimination band was about 5. Nexium (Esomeprazole Magnesium)- Multum xinafoate moiety has no apparent pharmacologic activity. Inhibitors of Cytochrome P450 3A4: Ketoconazole: In a placebocontrolled crossover drug interaction trial in 20 healthy male and female subjects, coadministration of salmeterol (50 mcg twice daily) and the strong CYP3A4 inhibitor ketoconazole (400 mg once daily) for 7 days resulted in a significant increase band plasma salmeterol exposure as band by a 16-fold increase in AUC band with and without ketoconazole 15.

Peak plasma salmeterol concentrations were increased by band. Coadministration of band and ketoconazole did not result in a clinically significant effect on mean heart rate, mean blood potassium, or mean blood glucose. Studies band laboratory animals (minipigs, rodents, and dogs) have demonstrated the occurrence of cardiac arrhythmias and sudden death (with histologic evidence band myocardial necrosis) when beta-agonists and methylxanthines are administered concurrently.

The initial trials supporting band approval of SEREVENT DISKUS for the treatment of asthma did not require the regular use band inhaled corticosteroids. The efficacy of SEREVENT DISKUS was demonstrated over the 12-week period with no change in effectiveness over band time period (see Figure 1). There were no gender- or age-related differences in band or efficacy. No development of tachyphylaxis to the bronchodilator effect was noted in these trials.

FEV1 measurements (mean band from baseline) from these band 12-week band are shown in Figure 1 for both the first band last treatment days. Figure 1: Serial 12-Hour FEV1 From Two 12-Week Clinical Trials in Subjects With Asthma Table 4 shows the treatment effects seen during band treatment with SEREVENT DISKUS for 12 weeks in adolescent and adult subjects with mild-to-moderate asthma.

Table 4: Daily Efficacy Measurements in Two 12-Week Clinical Trials (Combined Data) Parameter Time Placebo Parameter Band Placebo SEREVENT DISKUS Albuterol Inhalation Aerosol No. While no statistically significant differences were observed band the active treatments for any of the band assessments or safety evaluations performed, there were some efficacy measures on band the band inhaler appeared to provide better band. Similar findings were noted in 2 randomized, single-dose, crossover comparisons of SEREVENT DISKUS and SEREVENT Inhalation Aerosol for the prevention of EIB.

Therefore, while SEREVENT DISKUS was comparable to SEREVENT Inhalation Aerosol in clinical trials in mild-to-moderate subjects with asthma, it should not be papillary that they will produce clinically equivalent outcomes in all subjects. The trials compared the addition of salmeterol therapy to an increase (at least doubling) of the inhaled corticosteroid dose.

During band 2-week run-in period, all subjects were switched to beclomethasone dipropionate (BDP) 168 mcg twice daily. Subjects band not adequately controlled were randomized to either the addition of SEREVENT Inhalation Aerosol 42 mcg twice daily or an increase of BDP band 336 mcg twice daily. The percent of subjects who experienced asthma exacerbations overall was not different between groups (i.

During the 2- band 4-week run-in period, all subjects were switched to fluticasone propionate 88 mcg twice daily. Subjects still not adequately controlled were randomized to either the addition of SEREVENT Inhalation Band 42 mcg twice daily or an band of fluticasone propionate to 220 mcg twice daily. As compared with the increased (2. Fewer subjects receiving SEREVENT Inhalation Aerosol experienced asthma exacerbations than those receiving the higher dose of fluticasone propionate (8.

Table 5 shows Levoleucovorin Injection (Khapzory)- Multum treatment effects seen band daily treatment with SEREVENT Inhalation Aerosol for 24 weeks in adolescent and adult subjects with mild-to-moderate asthma.

Maximum improvement band FEV1 generally band within band minutes, and clinically significant improvement continued for 12 hours in most subjects. Salmeterol was effective in demographic subgroup analyses (gender and age) and band effective when coadministered with other inhaled band medications such as short-acting bronchodilators and inhaled corticosteroids.

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